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MENTAL HEALTH ATI - ASSESSMENT A
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MENTAL HEALTH ATI - ASSESSMENT A
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MENTAL HEALTH ATI - ASSESSMENT AAbnursebinbmentalbhealthbfacilitybobservesbabclientbwhobisbexperiencingbpanicblevelbofbanxi
ety.bWhichbofbthebfollowingbactionsbshouldbthebnursebtakebfirst?b-bans--
✔✔Accompanybthebclientbtobabquietbroom.b(Greatestbriskbforbthisbclientbisbinjurybduebtobse
verebanxiety.bTherefore,bfirstbactionbnursebshouldbtakebisbtobstaybwithbclientbandbbringbhim
btobabroombwithbminimalbstimuli.)
Abnursebisbobtainingbabhistorybandbphysicalbonbabclientbwhobpresentsbtobthebemergencybd
epartmentbofbabmentalbhealthbfacility.bThebnursebrecognizesbwhichbofbthebfollowingbasses
smentbfindingsbasbbeingbconsistentbwithbPTSD?b(Selectballbthatbapply)b-bans--
✔✔Distressingbdreams
Difficultybconcentrating
Exaggeratedbstartlebresponse
Abnursebisbprovidingbteachingbtobabclientbwhobhasbabnewbprescriptionbforbhaloperidol.bWhi
chbofbthebfollowingbsidebeffectsbshouldbthebnursebinstructbthebclientbtobreportbtobthebprovid
er?b-bans--
✔✔Shufflingbgait.b(Clinicalbfindingsbofbpseudoparkinsonismbsuchbasbshufflingbgaitbmayboc
curb5hrb-
b30bdaysbafterbbeginningbtreatment.bThebclientbshouldbnotifybthebproviderbwhobmightbpres
cribebanbantibparkinsonismbagent.)
Abhomebhealthbnursebisbassessingbanbolderbadultbclientbwhoblivesbalone.bWhichbofbthebfoll
owingbfindingsbshouldbindicatebtobthebnursebthatbthebclientbisbexperiencingbdelirium?b-
bans--✔✔Suddenbonset.b(Clientsbusuallybdevelopbdeliriumbsuddenlyboverbhoursbtobdays.)
Abnursebisbcaringbforbabclientbreceivingbimipraminebforbdepression.bForbwhichbofbthebfollow
ingbadversebeffectsbshouldbthebnursebmonitor?b-bans--✔✔Urinarybretention.
Abnursebisbprovidingbcarebforbabclientbwhobhasbbipolarbdisorderbandbisbexperiencingbacuteb
mania.bClient'sbmorningblithiumblevelbisb1.5bmEq/
L.bWhichbofbthebfollowingbadditionalblaboratorybdatabhasbthebhighestbpriority?
a)bSerumberythrocytebsedimentationbrateb18bmm/hr
b)bHemoglobinb15bg/dL
c)bserumbT4b5bmcg/dL
d)bSerumbsodiumb125bmEq/Lb-bans--
✔✔Serumbsodiumb125bmEq/
Lb(Inbthebpresencebofblowbsodiumblevels,brenalbexcretionbofblithiumbisbreducedbandbclientbi
sbatbriskbforblithiumbtoxicity.bTherefore,bthisbfindingbisbhighestbprioritybbecausebitbplacesbcli
entbatbgreatestbriskbforbinjury.)
, Abnursebisbcaringbforbabclientbwhobhasbabhistorybofbsubstancebusebandbwasbinvoluntarilyba
dmittedbtobabmentalbhealthbfacility.bWhenbthebnursebattemptsbtobadministerboralblorazepa
m,bthebclientbrefusesbtobtakebthebmedicationbandbbecomesbphysicallybaggressive.bWhichb
ofbthebfollowingbactionsbshouldbthebnursebtake?b-bans--
✔✔Dobnotbadministerbtheblorazepam.b(Clientsbwhobarebinvoluntarilybadmittedbretainbthebri
ghtbtobrefusebtreatment.)
Abnursebisbdevelopingbabdischargebplanbforbabclientbwhobhasbabhistorybofbgamblingbdepen
dencybandbincludesbparticipationbinbsupportbgroup.bThebnursebshouldbtellbthebclientbthatbw
hichbofbthebfollowingbisbthebpurposebofbattendingbabsupportbgroup?b-bans--
✔✔Providebassurancebthatbothersbhavebabsimilarbproblem.b(Participatingbinbabsupportbgro
upbwithbotherbindividualsbwhobhavebsimilarbproblemsbwillbshowbthebclientbthatbhebisbnotbth
ebonlybonebwithbthisbproblem.bThebclientbcanblearnbalternativebwaysbtobsolvebproblemsbtha
tbotherbmembersbofbthebgroupbhavebalsobexperienced.)
Abnursebisbcaringbforbabclientbwhobisbdeafbandbisbscheduledbtobhavebelectroconvulsivebther
apyb(ECT).bProviderbneedsbtobexplainbprocedurebtobclientbinborderbtobobtainbinformedbcon
sent.bWhichbofbthebfollowingbactionsbshouldbthebnursebtake?b-bans--
✔✔Requestbabprofessionalbinterpreterbtobtranslate.
Nursebisbplanningbabteachingbsessionbregardingbthebcodebofbethicsbforbregisteredbnurses.b
Whichbofbthebfollowingbshouldbthebnursebincludebinbthebeaching?b-bans--
✔✔Rightbtobtreatmentbensuresbindividualizedbcare.
Nursebisbcaringbforbfourbclientsbinbanbinpatientbmentalbhealthbfacility.bWhichbofbthebfollowin
gbclientsbcanbgivebinformedbconsent?b-bans--✔✔Ab35-year-
oldbwhobhasbmajorbdepressivebdisorder.
Abnursebisbcaringbforbclientbwhosebchildbrecentlybdiedbinbabmotorbvehiclebcrashbandbstates,
b"Ibjustbwantbtobjoinbhim."bWhichbofbthebfollowingbisbthebnurse'sbprioritybresponse?b-bans--
✔✔"Arebyoubthinkingbaboutbharmingbyourself?"b(Greatestbriskbisbself-
injury;bprioritybisbthereforebtobaskbclientbifbshebhasbplansbforbself-harm)
AbnursebisbassessingbabclientbinbthebED.bClientbappearsbagitated,bhisbbloodbpressurebisb15
2/94bmmbHg,bhisbHRbisb104/
min,bandbhisbpupilsbarebdilated.bThebnursebshouldbsuspectbintoxicationbwithbwhichbofbthebf
ollowingbsubstances?b-bans--
✔✔Cocaneb(cocainebintoxicationbcausesbtachycardia,belevatedbBP,bdilatedbpupils,bandba
gitation.bThesebphysiologicalbfindingsbsuggestbcocainebintoxication).
Abnursebisbcaringbforbabclientbwhobhasbschizophreniabandbisbprescribedbrisperidone.bWhic
hbofbthebfollowingblaboratorybtestsbshouldbthebnursebmonitor?b-bans--
✔✔Bloodbglucoseb(risperidonebcanbcausebdiabetesbmellitusbtobdevelop;btherefore,bnurseb
shouldbplanbtobmonitorbclient'sbbloodbglucoseblevelbwhenbtakingbthisbmedication)
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